4653APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING P ROJECT IDENTIFICATION
., -
;'' APPLICATION'& PERMIT
L
BUILDING -`ELECTRICA-'PLUMBING -MECHANICAL
PERMIT NUMBER
., 4653
BUILDING
An REs
OOWWNER'S 4o J
1`•
DTY. ELECTRIC PERMIT FEE
PLANf'KI&IDATION
rr
NOV 2 S 1983 '
-
City of Cupertino
DATE OF APPLICATION
c%ONTTRAC'TORSV1V„. �`n' -
1 Q (, V iitA � �(�j.No. -
OUTLETS, -SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES• - 5.00/1.00
CONTRACTORS
DR �� 9�3 ao96
(�6.1 Q�� ����
APPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARRCHITECT ._
ENGINEER -
' LIC. No.
SIGNS, -.g,g0
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. - 3.00
AGGRESS ENG.
" ZIP';,
SPECIAL CIRCUIT ' 5.80
PERMIT VALIDATION -
EMP. METER;OR POLE INS. 15.00.
,APPLICANT S- -
AOOR ,
ADDRESS
MOTORS • SEE FEE SCH.
SERVICE CHANGE 10:00
LICENSED CONTRACTORS DECLARATION '
Zo
^ I hereby affirm that 1 an licensed under provisions of Chdpter 9
(wmmencing'with Section 7000) of Division 9 of the Business and
Profession, Cotte, and mry license is in full force and effect..
License Class Lia Number
Date 'Contractor
ISSUANCE DATE
-' +
p ELE T.
I PLG. MECH.,
❑ ❑
2
NOVO
,v V
- OWNER -BUILDER DECLARATION _
hereby aolun Ihul Lam exeb Llio.5 the messan Contractor's
p -
Low for [lie ity or coo teon.ch requires
Code: Any city or county which reGuiress permit to conatmeL alter,
permit to
improve, demolish, or repair h p structure, prior to its issuance, also
hey vires Ole applicant for such permit In file a signed statement Li that
License
9 fc,,io , Cod) tit Section 7s exem t the of om the
Law licensed pursuant with Sections o( the )of Division
Law less ad
Buslness and Pofesaions Code) or that he is exempt therefrom and
I BUI DING PERMIT
IN ORMATION
MISS.- el'{,IflIE-ER TO ORD
PERMIT IS NCE 6.00
-
vALunnON.'
oy�
SIFT.
,.,
ELEC. CONTR. , 'LIC: NO. r
�' -
ELEC:
TOTALhe
TTI
�'_ /
M Ll/y�rll-
CITY. _ PLUMBING PERMIL FEE
- aTpgIES
GJ,1ffsrY��-•�
TYPE CONSTR.
the hosis for Ilse ailogo l exemption. Any violation of Sectio07031.5
by any, applicant for o permit subjects lite applicant In a civil penally
of not more than five hundred dollars 155001.1:
*' '"
ALTER-DRAIN&VENT-WATER (EA.)4:00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and lite n m cture is no[
- BACK F LOW PROTECT. DEVICE 200
.
OCC.GROUP
_
REB. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4:00
intended or offered for sale'(Sce. 7044, Business and Professions
'Code: The Contractor's License Law docs nil apply to an owner of
Emptily who builds or improves thereon, and who dna such work
himsclf'or lhrnogh his own employees, provided thin such improve-
mentsarenotimendedurofferedforsale. If. however, the building
'
• FIXTURES -*PER TRAP 4.00
GAS-EA:SVSTEM-11NC.40UTLETS. 4.00
so, FT. FLOOR AREA
TOTAL ACREAGE
,
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving Nut he dill not build or im-
Prove for purpose of Sala.).
1 1, :IS OWRCr OI Ille property', am exau,i Vely contracting Wllh
. - .
GAS - EASYSTEM OVER 4 (EA..) 1.00
BUILDING USE
RES. IND'. CON PB Omer
1 1.0
INDUSTRIAL WASTE INTER. 20.00
licensed cmmractors m construct the project (Sea 7044, Business
and I'messimis Code lite Contractor's License Law does not apply
to un owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1'INC 5 V.B. 5.00 `
LAWN SPR IN KLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
,
o tracts for such projects withacuntractor(sl licenuA pursuam ui
I Contractor's License Law. '.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
Bate exempt under sec�,Ii.NP.C. Iirr this
n-.nn�l
Dam owner
WATER HEATER W/VENT ,4.00
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP, 4.00
W'ORKERS'COMPENSA'I' ION DECLARAI ION
-
I hereby affvm that I have•a certificate ofemsent In self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING .
ENG. SITE NO.
t copy thereof (Sec. 3800, Lab.CA
'
Policy No Companv
❑'Cetlil'ied copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ IN
ENERGY 24
Y ❑ N[:)
MISC.. REFER TO ORD.
CFRTIFICAI' Ii OP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE ' 6.00
FLOOD ZONE
A.L.U.C.
• COMPENSATION INSURANCE
,('Phis section need not he completed if the'pennit is for one
PLG. CONTE. LIC. NO.,
PLG.
TOTAL
Y 5 N�
•Y �- N�
-hundred dollar, (S 100) orless I - -
-
1 certify that in the performance of the,work for which thlsper-
mil is issued, I shall not employ any person in any manner v a to
GTV. MECHANICAL PERMIT FEE,
FEE SUMMARY
BUILDING
n, 00
f�
become subject to the Workers' Compensation Laws of California.
Date ' ' Applicant
NOTICE TO APPLICANT': If, after making this Cehtificale of Ex-
ALTER OR ADD TO MECH. 4,00
APPLIANCE 4.00
AIR HANDLING UNIT ITO 10,000C.F.M.) 3.00
PLAN CHECK
FEE
'.
caption, you should become subject to the Worker.,"Compensation
provisions of the Labor Code, you mail 1'orthwill, mrPly with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER Ig MC.F.M.) 5.00
SEISMICFEE
�.
• CONS"FRUCTION,LENDING AGENCY
EXHAUST HOOD WITH DUCT) 2.00
I hereby affirm 'that there is a construction lending agency for
the perGrrionce of the work for which this permiLis issued (Sec.
3077, C-iv.C.L
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's NameHEATING
Lender's Address
UNIT (OV ER 100,000 B.T.U.17.50'
ELECTRIC
VENTILATION FAN, (SINGLE) 3.00 •_
1 certify owt I have read this applicmiun and state that the above
information is correct. I agree to comply with all city and county
ordinances and stale lows refiling In building constnation, and
PLUMBING
BOILER-COMPI3 H. P. or„100,000 B.T. U.1 4.00
BOILER-COMP.IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
r^ '
act, by uuthorice reperty tarries ec this city to corer upon the
above -m authumed properlyfor utivesp of Loon purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ay in any way accrue against said City in consequence of the
ntmg of tht pertyltpertylt
�^{t1i
Mlm
_
MISC. - REFER TO ORD.
CONST. TAX
_
PERMITISSUANCE - 3.00
MECH. CONT. LIG NO.
MECH.
TOTAL
•
•TOTAL
Signature of Applic:i Dam
OFFICE COPY